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Suicidal behaviors: amultidisciplinary issue

Merike Sisask* 14th European Symposium of Suicide and Suicidal Behaviour, Tel AvivJaffa, Israel, 36September 2012 The 14th European Symposium of Suicide and Suicidal Behaviour (ESSSB) was held in Tel AvivJaffa, Israel, on 36 September 2012. The ESSSB is a biannual event, where people acting in the field of suicide research and prevention researchers, clinicians, gatekeepers (community facilitators who are in a position to direct vulnerable and high-risk persons into effective treatment), volunteers and survivors can meet, share experiences and present recent achievements in order to save lives all over the world. The 14th ESSSB offered a high-level scientific program with plenary and keynote lectures, symposiums, parallel session presentations and posters. The 14th ESSSB was visited by more than 1000 participants from 36countries.
Suicide is a major public health problem and it has been estimated that globally 877,000lives were lost to suicide in 2002 [1]. For several years, the highest suicide rates have been found in Europe, particu larly in Eastern Europe [2]. A recent study on the epidemiology of suicide shows that, during the last 50years, the heart of the problem of suicide mortality has shifted from Western Europe to Eastern Europe and now seems to be shifting to Asia [3]. Suicidal behaviorscompleted sui cides, attempted suicides and suicidal ide ationshould be handled as a multidisci plinary issue, hence it is vital to study vari ous aspects of this complex biopsychosocial phenomenon [4]. The presentations at the 14th European Symposium of Suicide and Suicidal Behaviour covered a wide range of relevant hot topics in suicidology: the epi demiology of suicidal behaviors in differ ent European regions, genetics and neuro biology, epigenetics, geneenvironment interactions, mood and other psychiatric disorders as major risk factors for suicide, nonsuicidal self-injuries, peculiarities of suicidal behaviors in different age groups (e.g., adolescents and the elderly) and pro fessions (e.g., the military), psychological models of suicidal behaviors, evidencebased treatment strategies and effective interventions for suicide prevention, post vention of suicide survivors, and several other more specific areas. The following paragraphs give a brief overview of selected plenary sessions and keynote lectures. John Mann (New York State Psychiatric Institute, Columbia University, NY, USA)

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*EstonianSwedish Mental Health & Suicidology Institute (ERSI), ie 39, Tallinn 11615, Estonia; and Tallinn University, Institute of Social Work, Narvamnt 25, Tallinn 10120, Estonia; Tel.: +37 265 165 50; Fax: +37 265 165 50; sisask.merike@gmail.com

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10.2217/NPY.12.63 2012 Future Medicine Ltd

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ISSN 1758-2008

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gave a lecture during the opening session, Where is suicide research going in the next decade? The pressing needs identified included biopsychosocial predictive mod els, clear outcome measurement of inter ventions, multidisciplinary teams capable of using multimodal methods, utilization of clinical assessment applications (labo ratory measures) with laptops and tablets, and the adjustment of suicide prevention programs to local needs. Last but not least, he emphasized the importance of genetic and epigenetic studies, inclusion of large numbers of subjects and conducting better studies on high-risk families. Several other keynote speakers had biologically oriented presentations. Gil Zalsman (Child Psychia try Division at Geha Mental Health Center and Sackler School of Medicine, University of Tel Aviv, Israel) presented Gene envi ronment and timing interaction in depres sion and suicidefrom genetics to animal model; Kees van Heeringen (University of Ghent, Belgium) spoke on Images of suicide: the contribution of neuroimaging to our understanding of suicidal behav ior; and Marco Sarchiapone (University of Molise, Italy) presented Aggression and suicide: is there a biological link? An interesting debate between Alan Apter (Feinberg Child Study Center, Schneiders Childrens Medical Center of Israel and Sackler School of Medi cine, University of Tel Aviv, Israel) and Diego De Leo (Australian Institute for Suicide Research and Prevention, Griffith University, Australia) was held about non suicidal self-injuries: Is nonsuicidal selfinjuries a separate diagnosis? The debaters argued why it should or should not be a separate psychiatric diagnosis and finally let the audience vote. A final decision was not reached and both debaters had plausible pros and cons. An important vulnerable target group for suicide prevention is children and adolescents. Madelyn Gould (College of Physicians and Surgeons, Mailman School of Public Health, Columbia University) had a keynote lecture, Epidemiology of adolescent suicidean update. Danuta Wasserman (National Centre for Suicide Research and Prevention of Mental IllHealth, Karolinska Institute, Sweden) introduced the subject Lifestyles, mental health and suicidal behaviors in European adolescents. Results from the SEYLE study: Saving and Empowering Young Lives in Europe. Ella Arensman (National Suicide Research Foundation and Department of Epidemiology and Public Health, University College Cork, Ireland) had a presentation about a problem common among young people, Suicide clusters and contagion: evidence, early identification and responding. The following speakers handled the issue of suicidal behaviors from a psychi atric point of view: Maria Oquendo (New York State Psychiatric Institute, Columbia University, USA) presented Predicting and preventing suicidal behavior in bipo lar disorders; and Franz Resch (Depart ment of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Uni versity of Heidelberg, Germany) presented Deliberate self-harm and suicidal behavior in the development of borderline personal ity disorder. There is always a need for effective interventions and treatments for sui cidal patients in general and for specific sub-groups. Barbara Stanley (College of Physicians and Surgeons, Columbia University) spoke about Brief interven tions with suicidal patients and David Brent (Child and Adolescent Psychiatry at Western Psychiatric Institute and Clinic, and University of Pittsburgh School of Medicine, PA, USA) discussed The art of wooing nature: searching for evidencebased treatments for adolescent suicidal behavior. Lars Mehlum (National Centre for Suicide Research and Prevention at the Faculty of Medicine, University of Oslo, Norway) presented Dialectical behav ior therapy for self-harming and suicidal adolescents. A public health approach was consid ered during the presentations by Alan L Berman (International Association of Suicide Prevention and the American Association of Suicidology, DC, USA), whose talk was titled Rethinking suicide prevention: a public health problem with a mental health solution and Keith Haw ton (Centre for Suicide Research at Oxford University Department of Psychiatry,

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CONFERENCE SCENE UK), who presented Preventing suicide by restriction of access to means: rationale, successes and limitations. A presentation providing a psychological view on the topic of suicide was given by Rory OConnor (University of Stirling and the International Academy of Suicide Research, Scotland), Psychological processes and suicide risk: an integrated theoretical perspective, and Gustavo Turecki (McGill University, QC, Canada), How life events get under the skin: insight into the relationship between life adversity and suicide risk. Surpris ingly few presentations touched on the subject of associations between economic crises and suicide; only one keynote lec ture, by Paul Corcoran (National Suicide Research Foundation, Ireland), targeted this issue specifically with his presentation The impact of the economic recession on suicidal behavior in Ireland. Along with already well-known suicide risk factors such as depression, substance abuse, feelings of hopelessness and chal lenging life events, new social factors that intensively influence peoples lives have emerged and caught the attention of suicido logiststhe media and the inter net. These factors can have an impact on suicidal behaviors in different ways; they can act as a resource that either provokes suicidal behaviors or contributes to suicide prevention. The sociologically oriented plenary lecture by the current author, Merike Sisask, was titled Role of media in suicide preventionfriend or enemy and the main standpoints of this presenta tion will be introduced hereinafter in more detail. Media portrayal of suicidal behaviors can cause suicidal contagion (also known as imitative, copycat or mass cluster sui cides); therefore, responsible media report ing on suicidal behaviors is an important public health approach for suicide preven tion [59]. Several organizations dedicated to suicide prevention have launched and disseminated resources and educational materials for media professionals; for example, WHO [10], the Samaritans [101] and the American Foundation for Sui cide Prevention [102]. These materials have been translated and adapted by a number of countries and in some cases integrated into national suicide prevention strategies. However, not all countries in the world have such strategies. The resource for media professionals for suicide prevention published by WHO gives a short list of criteria that should be followed absolutely in order to cover the subject of suicide in the least harmful manner for vulnerable persons [10]: Take the opportunity to educate the public about suicide
Avoid language that either sensational

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izes or normalizes suicide, or presents it as a solution to problems

Avoid prominent placement and undue

repetition of stories about suicide

Avoid explicit description of the method

used in a completed or attempted suicide

Avoid providing detailed information

about the site of a completed or attempted suicide

Word headlines carefully Exercise caution in using photographs or

video footage
Take particular care in reporting celeb

rity suicides
Show due consideration for people

bereaved by suicide
Provide information about where to seek

help
Recognize that media professionals

themselves may be affected by stories about suicide Several studies have analyzed whether the manner of reporting about suicide is in line with the recommendations for the media, or whether the modification of media reporting about suicide can be achieved by educating media profession als (editors and journalists). The answer to the first question is too often no and the answer to the second question is mostly yes. Another important and more sophis ticated research question is whether inter ventions such as educating media profes sionals and changing the manner of suicide portrayal can have clear measurable out comes in terms of a decrease or increase in suicidal behaviors. Far less research is

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available measuring actual suicidal behav iorscompleted suicides, attempted sui cides and suicidal ideationbefore and after implementation of the media inter ventions. However, a systematic review dis covered that the vast majority of studies about the possible effects media reporting of suicidal behaviors might have on actual suicidality, support the idea that these two phenomena are associated [9]. The association can work in both ways. For indicating the negative, provocative effect of media portrayal, the expression Werther effect was introduced by Phillips [11]. It refers to Goethes novel The Sorrows of Young Werther , published in 1774, in which a young man takes his life for love by shooting himself. For indicating the preventive effect the expression Papageno effect was proposed recently by Nieder krotenthaler and his colleagues [12]. This refers to Mozarts opera The Magic Flute (1791), in which a young man in love becomes suicidal, but copes well thanks to his friends intervention. The system atic review by Sisask and Vrnik revealed that more research is available about how irresponsible media reports can provoke suicidal behaviors (the Werther effect), and less research has evaluated the protec tive effect media can have by newspaper References
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blackout or by changing the quality and content of media reporting[9]. In conclusion, irresponsible media pro fessionals can be enemies to and responsible media professionals can be friends for peo ple acting in the field of suicide prevention. Suicidologists should take the responsibility for educating and motivating media profes sionals to report about suicide adequately in a preventive manner. More evidence about the effects of introducing media guidelines on suicide reporting are needed. Next conference The next European Symposium of Suicide and Suicidal Behaviour will be held in Tallinn, Estonia, on 2730 August 2014 (www.esssb15.org).
Financial & competing interests disclosure
The author received a mobility grant for traveling to the 14th European Symposium of Suicide and Suicidal Behaviour from SA Archimedes, Estonia (Grant 16-3.3/1052). The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.

The World Health Report 2003: Shaping the Future. WHO, Geneva, Switzerland (2003). Bertolote JM, Fleischmann A. A global perspective in the epidemiology of suicide. Suicidologi 7(2), 67 (2002). Vrnik P. Suicide in the world. Int. J.Environ. Res. Public Health 9(3), 760771 (2012). Wasserman D, Wasserman C. Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford University Press, Oxford, UK (2009). Schmidtke A, Schaller S. The role of mass media in suicide prevention. In: The International Handbook of Suicide and Attempted Suicide. Hawton K, Van Heeringen K (Eds). John Wiley, NY, USA, 675698 (2000).
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Wasserman D. Strategy in suicide prevention. In: Suicide: An Unnecessary Death. WassermanD (Ed.). Martin Dunitz, London, UK, 211216 (2001). Pirkis J, Blood RW. Suicide and the media: Part I. Reportage in nonfictional media. Crisis 22(4), 146154 (2001). Mann JJ, Apter A, Bertolote J etal. Suicide prevention strategies: a systematic review. JAMA 294(16), 20642074 (2005). Sisask M, Vrnik A. Media roles in suicide prevention: a systematic review. Int. J.Environ. Res. Public Health 9(1), 123138 (2012). Professionals. WHO, Geneva, Switzerland (2008).

implications of the Werther effect. Am. Sociol. Rev. 39(3), 340354 (1974).
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A etal. Role of media reports in completed and prevented suicide: Werther v. Papageno effects. Br. J.Psychiatry 197(3), 234243 (2010).
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suicide and self-harm. www.samaritans.org/media-centre/ media-guidelines-reporting-suicide

102 American Foundation for Suicide Prevention.

10 Preventing Suicide: A Resource for Media

11 Phillips DP. The influence of suggestion on

suicide: substantive and theroretical

Reporting on suicide: recommendations for the media. www.sprc.org/sites/sprc.org/files/library/ sreporting.pdf

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